NURSING PROCESS IN THE CARE OF THE PRETERM INFANT

NURSING DIAGNOSIS
1. INEFFECTIVE BREATHING PATTERNS RELATED TO AN IMATURE DEVELOPMENT
OF THE LUNG AND CHEST WALL OR INSUFFICIENT AMOUNT OF SURFACTANT
2. ALTERED THERMOREGULTAION RELATED TO IMMATURITY OF HYPOTHALAMUS
AND LESS SUBCUTANOUS TISSUE GREATER SURFACE AREA TO BODY RATIO
3. POTENTIAL INFECTION RELATED TO IMMATURITY IMMUNE SYSTEM AND
ENVIRONMENTAL FACTORS
4. ALTERED NUTRITION LESS THAN BODY REQUIREMENT RELATED TO
IMMATURITY OF SUCKING AND SWALLOWING REFLEXES
5. POTENTIAL IMPAIRED SKIN INTEGRITY RELATED TO IMMATURE EPIDERMIS
6. PARENTAL KNOWLEDGE DEFICIT RELATED TO LACK OF EXPOSURE TO
ACCURATE INFROMATION

NURSING DIAGNOSIS : INEFFCETIVE BREATHING PATTERS RELATED TO AN

IMMATURE DEVELOPMENT OF THE LUNG AND CHEST WALL OR INSUFFICIENT
AMOUNT OF SURFACTANT
GOAL : The infant will be able to maintain normal respiratory rate between 4060/min. normal oxygen saturation between 85 95% and free of evidence
respiratory ditress
NURSING INTERVENTION
1. Position head up to 15 to support her respiratory efforts. Neck slightly
extended to open the airway.
2. Give appropriate oxygen therapy as needed to help decrease the infants
oxygen consumption
- Eg by nasal cannula , cpap , mechanical ventilation.
3. Maintain infant in neutral thermal environment
4. Give surfactant therapy
5. Monitor respiratory status pattern to determine further deterioration.
6. Moitor blood gases, pulse oximetry and notify physician of abnormal values

2. ND : altered thermoregulation related to immaturity of hypothalamus and less s/c

fat tissue, greater surface area body ratio.
Goal : baby axillary temperature is maintained between 36.5c 37c
1. Warm up body under preheated radiant warmer with servo controlmode set
at 36.5c 36.8c
- Temperature must 0.5 - 1 degree higher from axilla temp
- Avoid rapid warme to prevent vasodilation
2. Monitor baby temp every hour till stable
3. Use plastic wrap and place over the bedside to decrease ins the effect
insensible water loss and diminishing the effect of convection and
evaporation heat loss
4. Wear cap for head to cover larger surface area on infant and prevent heat
loss by convection
5. Use double wall incubator to minimize heat loss by radiation
6. Maintain ambient temperature between 26c 28c
7. Keep away radiant warmer from drafts etc aircond , fan to prevent heat loss
from convection and evaporation

3. ND : Potential infection to an immature immune system and environmental

factors..
GOAL: The infant has normal vital sign , normal perfusion, negative culture finding
and a normal blood glucose level and will be free of apnoea episode
1. Practice effective hand washing before and after contact to the baby to
prevent nosocomial infection.
2. Monitor vital sign every four hourly and as needed to detect sign of infection
eg : hypothermia , hyperthermia , hypothension , tachycardia or apnea
3. Document activity and responsiveness
- Assess feeding ability and gucose stability
- Observer for sign of lethargy , poor tone , poor feeding and glucose
istability of sepsis or extremely irritability can be indivative infection
4. Provide daily skin care (top n tail) and change linen and identify condition
that increase the risk infection such as extreme low birth weight ,
malnutrition or skin breakdown\
5. Use aseptic technic for all invasive procedure eg insertion i/v line, central line,
to reduce risk of septicemia.
6. Use individual item to prevent cross einfection
7. Encourage mother to express breast milk and give to baby
8. Change incubator every 1 week and clean daily (concurrent cleaning)
according to hospital protocol
9. Planned procedure to minimize handling to the baby
10.Start on prophylaxis antibiotic if baby is high risk infection.

4. ND : Altered nutrition less than body requirement related to an ability to suck

adequately because of weakness and immature reflexes (no coordination)
GOAL: infant will demonstrate consistent weight gain along with full feeding , will
receive adequate calories to support growth
1. Provide supplement enteral feeding with tube feeding or total parental
nutrition as ordered to conserve energy.
2. Give gavage feeding for infant 32-34 weeks as the dont have a coordinated
suck and swallow reflex
3. Position infant on right lateral site to improve gastric emptying.
4. Use proper size oof tube feeding before each feedin and check placement of
tube prevent aspiration pneumonia.
5. Record any gstric residual obtained before feeding
- Note colour and consistency of aspiration.
- Report abnormal finding
- Use 6 french feeding tube if 1000gm
- Hold syringe not more than 15cm 20cm and above the stomach.
- Place tube orally

6. Maintain strict intake and otput chart measurement to prevent dehydration or

overhydration.
7. Teach moter to assess infants readiness for breast feeding as evidenced by
observe respiration , normal muscle tone and alert state

5. ND : Potential impaired skin integrity related to immature epidermis.

GOAL : skin will remain intact without evidenced of breakdown.
1. Assess skin every shift to detect any skin injury , integrity , colour, perfusion
for oxygenation and sign in dehydration in skin trgor , change in temperature
and edema to prevent extensive tissue damage.
2. Minimize use off adhesive . use non hypoallergic product - avoid tape on any
infant <32 weeks and lesst than 7days of age as they are highest risk for skin
injury from adhesives because of the weak junction between the epidermis
and dermisl.
3. Use nonadhesive base electrodes and change electrode daily and as needed
if poor skin intergrity develops. Do not apllied over the nipples area to avoid
scarring of the tissue.
4. Remove adhesive slowly wiith water soakedcotton balls. Use a pressure
gauze dressing , not adhesive bandage for stasis bleeding
5. Rotate sited for temperature probes daily and pulse oximeter every shift.
6. Monitor iv sites , check iv patency before administering medication or blood
transfusion.
7. Turn and reposition immobilized infant every 3 or 4 hours
avoid pressure sore or constriction of blood flow from dressing , tubing ,
probes or cloth
- Place the infant in egg crake or sheepskin , type matrress to decrease
friction and pressure points.
- Repositioning promotes mobilization of dependant edema

6.ND : parental knowledge deficit( care of the preterm infant) related to lack of
exposure to accurate information.
GOAL : the parents will have realistic expatation of their preterm infant and will
have an adequate knowledge on care for the infant
1. Encourage parents to visit as often and they like
-

ND ; Altered nutrition less then the body requirement related to inability to suck
adequately because of weakness and immature reflexes.